01/31/2018

Heart disease remains the number one killer in the U.S. for both men and women. February is a great month to encourage your clients to renew their commitment to heart healthy habits

February’s focus on heart health is near and dear to me. My dear father had heart disease from the time I was 3 years old and died 10 years later, at age 56. I was only 13 at the time, and it changed my life. A cherished uncle followed, and then another uncle (my dad’s brothers). Years later my mom had a heart attack, which was the beginning of her health decline at age 80. Then, a few years ago, I was challenged with a heart arrhythmia – I was the same age my dad was when he died. I never thought I’d see the day when I was the heart patient! But I was fortunate to have great care at the Cleveland Clinic where an ablation procedure cured my symptoms. However, I am careful to follow lifestyle habits to avoid future issues. My story is not unique – more than 1 in 3 adults have at least one type of cardiovascular disease (1).

Anyone who knows me, knows that I have focused my career on improving nutrition care for older adults. Well, I’m celebrating a milestone birthday this month – and I’m getting closer to being an “older adult” myself! So my health is at the center of my thoughts. Just because I’m a registered dietitian nutritionist, doesn’t mean that I’m immune to health issues – or bad habits for that matter. Heart month is a time to renew the commitment to heart-healthy lifestyle habits. I hope this information will help you coach your clients to make changes to improve both the quality and quantity of their lives – so that their children can enjoy them for many years to come.

Background Information

About 1 of every 3 deaths in the US is a result of heart disease, stroke or other cardiovascular disease. There are some risk factors that cannot be controlled: age over 45 for men, over 55 for women, heredity (including race), or previous stroke or heart attack. But there are many risk factors that can be controlled: hypertension, tobacco smoking, hypercholesterolemia, physical inactivity, overweight/obesity, and diabetes. (2) Almost half (47%) of Americans have high blood pressure, high cholesterol, or are smokers (3), risk factors that can be addressed through lifestyle change.

Encourage your clients to know their numbers.

Heart disease risk is based on many factors. Each person will have goals for blood sugar, blood pressure, blood lipids (total cholesterol, LDL-cholesterol, HDL-cholesterol), and BMI based on their family history and medical condition, so encourage your clients to talk to their health care providers about setting goals. The “normal” targets are listed below:

Blood lipids: Goal levels vary for each individual depending on other heart disease risks (4) and treatment is recommended accordingly.

Blood pressure: 120/80 is considered normal. A BP of 130/80 is now used for a diagnosis of hypertension (5).

Fasting blood sugar: Less than 100 md/dL is considered normal; greater than or equal to 126 mg/dL is used to diagnosis diabetes (6)

A1c: 4 - 5.6% is considered normal; greater than or equal to 6.5% is used to diagnose diabetes. For those with diabetes, a higher A1c may be acceptable. (6)

Body Mass Index (BMI): 18.5-24.9 is considered a normal or healthy weight. (7)

Almost 1 in 3 American adults have high blood pressure, which is a major risk factor for first heart attack, stroke, chronic heart failure and kidney disease. (9,10) Smoking, eating high sodium and low potassium foods, physical inactivity, obesity and drinking too much alcohol are risks for hypertension. (11)

About 90% of Americans over age 2 consume too much sodium. (12) The Dietary Approaches to Stop Hypertension (DASH) eating plan is well known as an effective intervention for lowering blood pressure. There is an abundance of information about the DASH eating plan available from the National Heart, Lung, and Blood Institute.

It’s also helpful to reduce stress. Encourage your clients to take time out each day to relax, renew, and reenergize: go for a walk, do some deep breathing, enjoy their favorite music, yoga, meditation, a hot bath, or talking to a friend. Even 10-15 minutes a day can be helpful.

2. Control cholesterol.

Educate clients on the benefits of choosing healthy polyunsaturated fats found in liquid vegetable oils such as canola and soybean oil, and monounsaturated fats found in nuts, nut butters, olives, olive oil and avocados.

The American Heart Association recommends 5-10% of daily calories from omega fatty acids. (13) Omega-3 fatty acids can help lower triglyceride levels, and can be found in fatty fish, walnuts, flaxseed, eggs. (13) Vegetable oils are major sources of omega-6s. Substitute these over solid fats and tropical oils (coconut, palm and palm kernel oil).

This is especially important for people with diabetes, but important for others as well. Researchers have recently made the connection between high levels of sugar intake and heart disease. One study documented a 38% higher risk of CVD mortality for people who consumed 17-21% of their calories from added sugars compared to those who consumed 8% of calories from added sugars. This was largely consistent across age group, gender, healthy eating index, BMI or physical activity level. (14) This study indicated that the average sugar consumption of adults in the US is 22 teaspoons of sugars each day, which is more than 3 times the recommended level. Major sources of added sugars in the US diet can be found here.

Encourage clients to eliminate sugary beverages and foods for at least 30 days to break the habit; and drink unsweetened beverages such as water, sparkling water, diffused water (lemons, limes, cucumbers or fruit), or hot or iced tea. Start with limiting or eliminating obvious sources of sugar and switch to naturally sweet foods such as fruits. Remind them that raw sugar, honey and agave syrup are all simple sugars. Encourage label-reading and selection of choices that are lower in sugar. One more caution: some studies indicate that even artificially sweetened foods and beverages may still create cravings for sweets. (15)

4. Get active.

More than 80% of adults do not meet the 2008 Physical Activity Guidelines for Americans for both aerobic and muscle-strengthening activities. (16) Encourage clients to include physical activity on most days of the week. (People with health issues should get their doctor’s approval before starting an exercise program.) Exercising lowers blood pressure, strengthens the heart, helps maintain lean body mass, burns calories, and produces endorphins, the feel good hormone. Experts recommend at least 150 minutes of moderate-intensity physical activity, or 75 minutes a week of vigorous intensity aerobic physical activity, along with muscle strengthening exercises on 2 or more days a week for adults aged 18-64. (17)

People 65 and older, are also encouraged to follow the same guideline unless they are physically unable. In that case, they should be as physically active as they are able. They should also do exercises to improve balance and reduce risk for falls. For beginners, even 10 minutes at a time can be positive, and they can work up to the minimum of 60 minutes on most days to meet the recommendations. (17)

Fitness trackers or pedometers can motivate clients and keep you informed of their progress. I love the Fitbit feature that reminds you to do a minimum of so many steps every hour! It’s especially nice for people who work in sedentary jobs.

5. Eat better.

Sadly, US adults only consume vegetables about 1.6 times per day and fruit about 1.1 times per day. (18) Most Americans do not follow a healthy eating pattern, and as a result about 36% of US adults are obese (19). Start with encouraging individuals to follow a healthy eating pattern such as USDA Food Patterns, DASH-style diets, Mediterranean-style diets, Healthy Vegetarian Food Pattern as outlined in the Dietary Guidelines 2015-2020.

6. Lose weight (if overweight).

There are many benefits to losing weight and maintaining a healthy weight including better control of hypertension, blood sugar, and hypercholesterolemia. (20) Even a 10 pound weight loss can lower heart disease risk. There is an abundance of good information on this subject available so I won’t go into detail here. Controlling portion sizes of all foods is one simple way for your clients control their calorie intake.

7. Stop smoking.

Unfortunately 15% of US adults still smoke (21). Encourage your clients to stop smoking and refer them to a good smoking cessation program.

One more note: People sometimes alter doses or stop taking medications altogether which can cause negative health outcomes. Encourage your clients to take medications as prescribed, and talk to their doctor if they have concerns.

It takes time to develop new healthy habits. Encourage your clients to take one step that they believe they can be successful with, and move forward from there. The most important key is that they believe they can make changes that become lifelong commitments for better health and quality of life.

Becky Dorner, RDN, LD, FAND is widely-known as one of the nation's leading experts on nutrition, aging and long-term health care. Her company, Becky Dorner & Associates, Inc. is a trusted source of valuable continuing education and resources dedicated to improving quality of life for older adults. Visit www.beckydorner.com and sign up for the free membership.

11/06/2017

The smell of turkey roasting in the oven… The sight of the table set for a very special holiday gathering… Candles glowing brightly…Festive holiday music... The flavor of your favorite holiday dessert melting in your mouth… Hugs and laughter with the people you love the most.

These are some of the special delights that elicit wonderful, heartfelt memories of holiday celebrations with family, friends, food and fun. But holidays can be a challenging time for older adults. We often get questions from people on therapeutic diets: “How strictly do I have to follow my diet during the holiday?” “Can I enjoy some of my favorite foods?” “Is it OK to ditch my diet and take a ‘diet holiday’”?

People want to enjoy festive foods on special occasions - without feeling guilt or suffering from negative outcomes. Holiday gatherings are an opportunity to enhance quality of life for our older loved ones. Here are a few examples.

Glen is happy to have made it to 90, but he suffers from heart failure (HF), COPD, and emphysema. His doctor has had him on a strict 2000 mg sodium diet for over a year. Since then he has lost 45 pounds, from 145 to barely 100 pounds on his 5’4” frame. He eats fairly well when meals are prepared and someone sits and eats with him. He was recently placed on home hospice, but his attitude is generally good, and with a reduction of his medications from 22 pills a day down to about 9, he seems to be fairly stable. His caregivers worry about his salt intake since the doctor said he needed to follow a strict low sodium diet. As his registered dietitian nutritionist, what advice should you give them? I’d say, “Ditch the diet!”

Doctors often order a 2000 mg sodium diet with a 2000 mL fluid restriction per day, but evidence indicates decreased hospital readmissions and mortality in patients with compensated congestive HF on a 2000-3000 mg sodium a day (1,2). And since Glen is on hospice care, diet rules go out the window. Generally, patients are encouraged to eat whatever they want and symptoms are controlled with medications. Since Glen is so emaciated, this would likely be the best approach to take with him at this point in time. Encouraging him to eat the foods he loves, along with a high calorie/high protein supplement if he’ll take it. Cream soup, pudding, cream pie, milkshakes, ice cream and other similar foods would also provide needed calories and protein if acceptable to Glen. At the end of life, as long as the hospice nurses continue to monitor his breathing, blood pressure, and edema, let him eat whatever he is willing to eat.

Glen’s wife, Mary, is 89. She has hypertension and had a myocardial infarction with stent placement at age 80. She has been following a low fat, low cholesterol, 2 gram sodium diet ever since. She has developed moderate cognitive impairment with unintended weight loss in the past year as her husband’s illness has taken its toll on her. Mary is still fairly independent with her activities of daily living and she gets around fairly well. She needs someone to prepare her meals and clean the house, but she still likes to make herself useful. She has no swelling in her lower extremities and does not exhibit any other symptoms of hypertension or cardiac distress. What would you recommend for Mary’s diet? Since she has also experienced weight loss and is more frail now than she was a year ago, at 89 Mary should probably also ditch the diet!

Be aware of cardiac problems while balancing clinical status, prognosis, and risk for malnutrition. If blood pressure control and lipid reduction are goals for Mary, monitor her blood pressure frequently and encourage her to take her medication to achieve these goals and still allow her to enjoy personal food choices (3). Physical activity based on Mary’s abilities (4), along with a liberalized diet encouraging a variety of healthy foods with moderate sodium levels may be the best approach. The 2015-2020 Dietary Guidelines for Americans (5) and the Dietary Approaches to Stop Hypertension (DASH) diet can also help. The DASH eating pattern is known to reduce BP (6,7).

Remember to assess for malnutrition with interventions as appropriate to improve nutritional status (4). Assure that Mary gets plenty of protein in her diet. Older adults should strive for 30 grams of protein per meal. In combination with weight bearing exercise, this can help Mary maintain her muscle mass and strength.

Glen and Mary’s son John is also an older adult at 70 years of age. He is overweight, has hypertension and hypercholesterolemia with multiple risk factors for cardiovascular disease. John lives independently and is very active. He travels a number of times a year, golfs, putters around with wood crafts, and has a healthy social life. John loves a good meal as well as a good cocktail hour every evening. He also loves to snack, attend parties with friends and family, and tends to over eat and drink during these occasions. For the “young older adult” like John whose goal it is to prevent cardiovascular disease and dementia, you might recommend that he follow a Mediterranean Style Eating Pattern or MIND Diet. There are many sources of information on these diets, but here is a sample diet guideline on the Mediterranean-style Diet.

Here are some healthy holiday eating tips you can share to enjoy the festivities without paying a heavy price in the days after the event.

Every individual is unique and our advice should be tailored to individual needs. Generally speaking, most frail older adults can probably throw the rules out for a special holiday meal. Healthier older adults that are trying to reach certain goals can use our help to make these occasions special with a little advanced thought and planning for a healthy and fun celebration for everyone. Enjoy the festivities!

U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans 2015–2020. 8th Edition. December 2015.http://health.gov/dietaryguidelines/2015/guidelines/.

Becky Dorner, RDN, LD, FAND is widely-known as one of the nation's leading experts on nutrition and long-term health care. Her company, Becky Dorner & Associates, Inc. (BDA) is a trusted source of valuable resources dedicated to improving quality of life for older adults. For valuable resources for healthcare professionals, visit www.beckydorner.com and sign up for our free membership.

03/24/2017

As the RDN for a continuing care retirement community, you have been asked to do a presentation and a booth on good nutrition for older adults at an upcoming health fair. The audience will include past rehabilitation patients from middle age to older adults with a diverse range of health issues – ranging from knee or hip replacement surgery and post cardiac events, to people with multiple chronic diseases including hypertension, diabetes, cardiovascular disease, malnutrition and unintended weight loss.

Information about nutrition is everywhere, and as a result many people have misconceptions about the role that food and supplements can play in maintaining health. “Fad” diets for weight loss or good health can be difficult to follow, might not have any benefit, and could actually be harmful. But with only 45 minutes to speak to such a diverse audience, how do you decide what is most important to discuss? Use the tips below to help you form your program.

Nutrition for Older Adults

Older adults have the same basic nutritional needs as younger adults, with a few exceptions. As we age, our energy needs decrease, which means that we need less food to maintain weight - and eating too much can result in weight gain. Consuming nutrient dense foods is essential for good health. Following the guidelines found at ChooseMyPlate.gov can help older adults make good food choices from the 5 food groups outlined: vegetables, fruits, grains, protein foods and dairy foods. ChooseMyPlate recommends specific amounts and portions of each food group for good health. It is a template that can be used to plan healthy menus to meet the needs of most older adults, including those with cardiovascular disease, diabetes and/or hypertension.

Eating foods from all the food groups will provide the protein, calories, vitamins, minerals, fluids, and fiber that older adults need for good health. ChooseMyPlate recommends non-meat sources of protein (such as nuts and nut butters, beans and soy foods) for those who don’t eat meat, and use of whole grains (whole wheat bread, oatmeal, popcorn and others) as part of the grain group. Unless a person has a specific health problem (such as lactose intolerance) that requires avoiding a food group (such as dairy foods), foods from all groups should be included on a daily basis.

Diet Alterations, Food Habits and Supplementation

Some older adults may need to decrease the amount of sodium or sugar that they consume. Some may need to alter the types and amounts of fats they use. Many will need to increase fruits, vegetables and whole grains.

Food habits take a lifetime to build, and can be difficult to change. If a person has never been a breakfast eater they aren’t likely to change that habit as they age. If a person was a dessert eater at every meal, that may be a habit that they will not want to give up. Food and meals play a big role in quality of life for older adults. Eating a healthy diet is important but that should be balanced with the pleasure of eating and enjoying favorite foods that some might consider “unhealthy”. There are really no “good foods” and no “bad foods”. Older adults are encouraged to eat healthy foods, but they can also include some foods that provide comfort and pleasure.

Because food habits can be hard to change, it is probably not realistic for an older adult who has been overweight most of their life to lose weight, or for someone who has been very slender to put weight on. Some older adults who want to lose weight can be successful, but it is important not to restrict food intake too much because it can compromise health.

Health problems (such as new medical problems or a decreased appetite) might affect an older person’s nutritional needs. Some older adults may need a vitamin supplement. Shortfall nutrients such as calcium, vitamin D, and B-12 are some of the vitamins that are commonly prescribed for older adults. A daily multivitamin might be a good idea if a person has a poor diet, but it is not a “magic potion” that will keep someone healthy. Conversely, vitamin and/or herbal supplements can interfere with some prescription medication so it’s important to check with a doctor before taking any of these over the counter remedies.

Key Nutrition Messages for Older Adults

Spend some time on ChooseMyPlate.gov to refresh yourself on the basics of good nutrition. It is a good idea to select a few major points that will be of interest to the entire group. For example:

Eating a healthful diet, using guidelines such as ChooseMyPlate as a template, is important to good health.

Include vegetables, fruit, dairy foods, good sources of protein, and grains in the recommended amounts and portion sizes daily.

There are no “good” or “bad” foods; all foods can fit in a healthy diet. Good food adds pleasure to our lives and should be enjoyed.

Every person is different so what is good for one person may not be appropriate for another. A registered dietitian nutritionist (RDN) is a trusted resource for easy to follow, individualized nutrition advice to match your lifestyle and health needs.

Your audience may have specific questions about their own health and nutritional needs that should not be addressed in a group setting. Encourage them to make a private appointment with you, or if you prefer, refer them to the Academy’s Find an Expert page.

Becky Dorner, RDN, LD, FAND is widely-known as one of the nation's leading experts on nutrition and long-term health care. Her company, Becky Dorner & Associates, Inc. (BDA) is a trusted source of valuable resources dedicated to improving quality of life for older adults. For valuable resources for healthcare professionals, visit www.beckydorner.com and sign up for our free membership.

01/12/2017

Richard is an 88 year old male who was hospitalized post myocardial infarction (MI) for placement of a stent and management of heart failure. Other than a diagnosis of hypertension which has been under control with medications since age 70, he had been healthy and living independently with his wife in their home. Prior to the MI, he was eating a regular diet and either walking or using a stationary bike daily. However since the MI, his cardiologist has drastically restricted his physical activity, and ordered a low fat, low cholesterol, 2 gram sodium diet. His medications include 75 mg atenolol daily, 40 mg Lasix twice a day, 80 mg Lipitor daily, 8 mg warfarin daily, 75 mg Clopidogrel daily, and 80 mg low dose aspirin daily.

At 5’5” tall, normally 145#, he has gradually lost weight and is now down to 106#. Although his food intake is only fair, his cardiologist emphasized the need for a low sodium diet and daily weights to monitor for fluid shifts. His wife is overwhelmed and his daughter is nervous about how to shop and prepare for his meals.

Knowing that almost 20% of older adults are readmitted to the hospital within 30 days of discharge (1), assuring Richard receives good advice is essential. He will be returning home with his 88-year old wife, who is overwhelmed and nervous about preparing his food and with limited help from family. How should you counsel Richard?

Malnutrition Concerns

Medical nutrition therapy (MNT) recommendations for cardiovascular disease (CVD) in older adults vary based on diagnosis, age and risk of malnutrition. For frail older adults, unintended weight loss, malnutrition, sarcopenia, and frailty are genuine concerns. These conditions can lead to reduced functional ability and increased dependence, so preventing these complications is critical. Consuming nourishing food to prevent further decline is a major focus.

Health care providers mean well by ordering therapeutic diets to improve health, but in frail older adults, these diets can have a negative effect on the variety, flavor, and palatability of food. This can reduce enjoyment of eating, decrease food intake and lead to complications that could affect quality of life and longevity. It is critical to individualize nutrition interventions to assure the highest level of well-being for each person, and in many cases that means avoiding strict therapeutic diets. According to the Academy of Nutrition and Dietetics (Academy) Evidence Analysis Library, more liberal diets are associated with increased food and beverage intake in older adults (2).

Medical Nutrition Therapy for Cardiovascular Disease in Older Adults

A risk factor for cardiovascular disease, hypertension affects approximately 64-78.5% of older adults (3). Lowering blood pressure can help reduce risk for stroke, MI, heart failure, and renal disease. For people 60 years or older, blood pressure (BP) goals are <150 systolic and <90 diastolic BP (<140 and <90 for people with diabetes and/or CDK). All adults with hypertension should modify their lifestyles in conjunction with pharmacological treatment (4). To maintain nutritional status, older adults may need a more liberal approach to sodium restriction, especially if they are already frail (5).

Heart failure (HF) is the leading cause of hospitalization among older adults in the U.S., and more than 50% of HF patients are readmitted within 6 months of hospital discharge (6). Treatment includes medications, a reduced sodium diet, and daily physical activity (7). A 2000 mg sodium, 2000 mL fluid restriction is typically prescribed (8), however recent evidence indicates that intake of 2700-3000 mg sodium daily may decrease hospital readmissions and mortality in patients with compensated CHF (9).

Current guidelines for older with atherosclerotic heart disease recommend a focus on overall risk factors rather than specific parameters for blood lipid levels (10). It is unclear whether or not modification of blood lipids is effective to prevent CVD in older adults (11). Lipid levels can be controlled by medications while allowing an older person to enjoy food.

How Should Richard be Counseled?

In Richard’s case, dietary changes should be balanced with his condition, prognosis, threat of malnutrition and cardiac cachexia, and individual food preferences. Richard should be counselled on eating healthfully to help maintain his health and focus on enjoying his meals. The Dietary Guidelines for Americans (DGA), the Dietary Approaches to Stop Hypertension (DASH) eating pattern, or a Mediterranean style diet are all good eating patterns for Richard. If Richard’s food intake is poor or he is resistant to these suggestions, a more individualized eating pattern that includes his favorite foods may be needed, even if those favorites are high in sodium or fat.

The Bottom Line for Older Adults with CVD

It is important to assure person directed choice when working with older adults. Decisions should be informed and in coordination with the individual’s goals, preferences and choices. Most older adults with CVD can benefit from a diet based on the DGA which is moderate in fat, cholesterol, sodium, and added sugars. Evidence suggests that frail older adults often need a less restrictive diet to offset the risks of unintended weight loss and malnutrition.

Becky Dorner, RDN, LD, FAND is widely-known as one of the nation's leading experts on nutrition and long-term health care. Her company, Becky Dorner & Associates, Inc. (BDA) is a trusted source of valuable resources dedicated to improving quality of life for older adults. For valuable resources for healthcare professionals, visit www.beckydorner.com and sign up for our free membership.

James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2013;311 (5): 507-520. doi:10.1001/jama.2013.284427.

08/15/2016

Your 76 year old patient Edna proudly tells you that without even trying, her weight is down from 145 to 124 pounds in just 6 months. At 5’1” tall and 145 pounds her BMI was 27.4 which was considered overweight for her height. Now at 124 pounds she is in the normal weight category. So do you cheer for her? Or do you worry that she may have some serious health repercussions?

Estimates indicate that more than 33% of people over 65 years of age (1), and almost 26% of newly-admitted nursing home patients are obese (2). Predictions are that these numbers will continue to rise, so it’s likely that you will see more obese older adults in your practice (3)

Research has reported reduced risk of mortality, reduced development of type 2 diabetes and improved cardiovascular risk factors with intentional weight loss in older persons (4). Weight loss can also result in improved physical functioning, which can improve quality of life (5). Moderate planned weight loss in obese older adults may have beneficial effects on comorbidities, functional performances, and quality of life if regular physical activity is included (6).

The Obesity Paradox

However, in recent years, questions have been raised about the health risks of obesity in older adults. The “obesity paradox” is a term that describes the fact that obesity appears to be protective from disease and death in some individuals. A growing body of evidence indicates that overweight and obese older adults are not at greater mortality risk than those who are normal weight (7,8). For example, in acute and chronic heart failure, overweight and mild to moderate obesity is associated with improved survival (9). Obesity can appear protective among individuals with cardiovascular disease (10), and normal weight adults have higher mortality risk than obese patients with type 2 diabetes (11).

In older adults, there may be other protective effects associated with being slightly overweight. Overweight seniors may be more likely to survive acute illnesses, handle stress better and recover more quickly from traumas as a result of excess nutritional reserves. Research will continue to explore the relationship between obesity and health, but it is clear that the health implications of obesity, particularly in older adults, are complicated.

In some cases maintaining an older adult’s usual body weight (UBW), is more appropriate than initiating weight loss. For example, weight management in older people with CVD should aim to improve and maintain physical function and quality of life rather than prevent medical problems associated with obesity (12).

There is strong evidence that unintended weight loss leads to increased morbidity and mortality (13), so you should carefully weigh the risks versus benefits of weight loss for each individual. The safety of weight reduction must be the priority to avoid the potential for malnutrition, vitamin/mineral deficiencies, and other potential complications such as bone loss, weakness, falls, and other problems. Planned weight loss is NOT appropriate for frail elderly, those with serious medical conditions that threaten mortality, patients with dementia, hospice patients, or people who don’t want to lose weight.

Challenges to weight management

If you do decide to move forward with a weight management program for an older client, the goal must be to promote gradual weight loss and maintain health. Metabolism declines with aging, so older adults require fewer calories to meet their energy needs and even fewer to lose weight, making a well-balanced diet difficult to achieve. Combining calorie reduction, increased physical activity, and behavioral strategies is one key to success (4). You will need to carefully plan and supervise the program to assure that it continues to be planned weight loss and not unintended weight loss which might indicate occult disease. Proper nutritional counseling and close monitoring of body weight and other nutritional parameters are essential. If possible, physical activity including weight bearing exercise and/or strength training should be included to help prevent loss of lean body mass and increase chances for successful weight loss (14).

So let’s get back to Edna…

Although formerly exercising daily on her stationary bike and using her bands for resistance training, Edna is having a lot of pain due to her advancing issues with arthritis, and this has slowed her exercise routine to nearly nothing at all. In her case, this unintended weight loss should send major red flags to you as her RDN. She is likely experiencing sarcopenia with her unintended weight loss, and this may be the beginning of a downward spiral of health issues.

A nutrition focused physical assessment may reveal that Edna is showing signs of fat and muscle depletion, and a nutrition intake study may indicate that Edna eats a fairly healthy lunch, but she fills up on empty calorie foods in the morning and evening. Using the Academy of Nutrition and Dietetics criteria for diagnosing malnutrition, we can see that Edna likely has chronic disease related malnutrition. Her unintended weight loss may have led to muscle weakness which in turn may lead to weakness, decreased abilities to perform activities of daily living (such as shopping and cooking), falls and other health declines.

You will want to ask a lot of questions and gather all the information you can on Edna’s current eating and activity habits, so you can complete an accurate nutrition assessment with appropriate nutrition diagnosis, interventions, and a monitoring/evaluation plan. The Mifflin St. Jeor equation is the most accurate formula to assess her caloric needs (unless you are lucky enough to have indirect calorimetry available which is the gold standard), and protein needs will be a minimum of 1.0 g/kg body weight.

As you assess Edna or any of your obese older patients and clients, a number of questions must be answered before determining whether weight loss is appropriate: Will weight loss reduce risk factors for other complications? Will weight loss prolong life for the individual? What are the risks associated with obesity treatment? Will a diet that restricts calories reduce the individual’s ability to consume adequate nutrients to maintain health (15)? Only after answering these questions can you determine the approaches that will be best for your clients.

Becky Dorner, RDN, LD, FAND is widely-known as one of the nation's leading experts on nutrition and long-term health care. Her company, Becky Dorner & Associates, Inc. (BDA) is a trusted source of valuable resources dedicated to improving quality of life for older adults. For valuable resources for healthcare professionals, visit www.beckydorner.com and sign up for our free membership.

03/23/2016

Have you ever swallowed and had food “go down the wrong way”? For an estimated 15-40% of adults over the age of 60 this is a constant concern. Dysphagia is simply defined as any difficulty or inability to swallow. It is not a disease, but a disruption of a normal process. Problems at any point during the swallow can result in difficulty swallowing. A person with dysphagia may have a delayed, incomplete or absent swallowing response. Potential causes include obstruction, nerve and muscle problems and miscellaneous issues such as trauma, medications, poor dentition and poor mouth care. Dysphagia can have a dramatic impact on an older person’s nutritional status including development of malnutrition, unintended weight loss, dehydration, and other nutrition deficits.

Warning Signs of Dysphagia

Dysphagia sometimes goes undetected because the signs and symptoms may be confused with other problems or conditions. Warning signs include:

If signs of swallowing problems are identified, referral should be made to the appropriate health care professional(s) to screen for dysphagia and assess for problems with dentition, pocketing of food in the mouth, pooling of liquids, suspected aspiration, risk of unintended weight loss and malnutrition. The EAT-10: A Swallowing Screening Tool may be used for screening, and a bedside swallow evaluation may be completed to determine need for further testing.

Diagnosis and Treatment

Tests may include a fiber-optic endoscopic evaluation procedure (FEES test) or video fluoroscopic swallowing study. Diagnosis of the type of dysphagia depends on the origin of the problem:

Oral Dysphagia: Difficulty initiating a swallow due to difficulty chewing, manipulating food in the mouth or propelling food to the back of the throat.

Pharyngeal Dysphagia: The food bolus penetrates the larynx due to a delayed swallow reflex, incomplete closure of the larynx or residues remaining in the pharynx after the swallow.

Esophageal Dysphagia: Food does not move easily through the esophagus due to esophageal dysmotility, structural blockage, stenosis or strictures due to gastro-esophageal reflux disease (GERD).

Once the type of dysphagia is diagnosed, treatment goals include: promoting a safe swallow to reduce risk of choking and/or aspiration of food and fluid into the lungs; maintaining good nutritional status and adequate hydration; facilitating independent eating and swallowing; enhancing the enjoyment of eating and quality of life.

The interdisciplinary team and the patient work together to determine the most appropriate strategies for each individual. Traditional treatment strategies include: swallowing exercises and techniques to improve ability to gather food particles together, thermal stimulation, changes in food/fluid temperature, good oral care to reduce aspiration pneumonia, alterations in food texture and/or fluid consistencies, alternating sips of liquid with food, proper positioning to ease swallowing, close monitoring and intervention during meals and snacks, and/or adaptive equipment such as modified cups or straws.

Controversies in Dysphagia Management

Puree or mechanical soft food or thickened liquids are often recommended to treat dysphagia and prevent aspiration pneumonia. The thought is that cohesive foods tend to be easier to control in the mouth and easier to swallow, and thickening liquids slows the time it takes for the fluid to move through the mouth and esophagus and allows better control of the swallow. However, many experts now believe that evidence does not support diet modification for reducing aspiration pneumonia. Several studies demonstrate that positioning and/or modification of dietary consistency or texture does not reduce aspiration events in persons with dysphagia. As a result, the standard of care for dysphagia management may be changing, especially for management of older adults in skilled nursing facilities.

Swallowing abnormalities are common in older adults but do not necessarily require modified diet and fluid textures, especially if these restrictions adversely affect food and fluid intake. Some individuals with dysphagia may request regular food and/or liquids because they don’t like the diet that is ordered. In nursing homes, all decisions on texture and consistency-modified diets should defer to the person (and/or family) after medical advice on the risks and benefits have been provided. If the individual and/or the family refuse recommended treatment, the facility should document that they have educated the individual and/or family, and request an adjustment of the physician’s orders and care plan to honor informed choice.

Developing a Care Plan for Dysphagia Management

Even though the standard of nutrition care for dysphagia is changing, and new recommendations may be released in the future as new evidence is made available, texture modifications, fluid consistency alterations, and proper positioning continue to be the standard of care for dysphagia treatment in many healthcare settings.

The interdisciplinary team, including the RDN and SLP should work together to individualize the care plan for each patient. The RDN should complete a thorough nutrition assessment that includes medical factors affecting food/fluid intake, nutrition-focused physical assessment with emphasis on condition of the teeth and oral cavity, nutritional needs, weight history, evaluation of lab tests, risk of malnutrition, dehydration and unintended weight loss, food habits/preferences, ability/willingness to adhere to consistency modifications. A physician’s order should reflect the results of the evaluations and specify food texture and fluid consistency needed. In nursing facilities, quality of life and an individual’s right to make choices about their care are important considerations, and all decisions regarding diet orders for dysphagia should default to the individual. Their right to refuse recommended treatment should also be respected.

Once treatment has been implemented, regular monitoring and evaluation should include assessing weight over time to identify unintended weight loss, monitoring hydration status, evaluating food/fluid intake, assuring proper feeding assistance and positioning, assuring foods provided are of the appropriate consistency, and monitoring for signs and symptoms of swallowing problems. If intake of foods and fluids is very poor and/or nutritional status is highly compromised, enteral feeding should be considered if consistent with the goals of care.

Older adults with dysphagia can still enjoy mealtime with the right interventions and treatment – and quality of life and enjoyment of food should continue to be the focus.

02/11/2016

I do my best to stay positive in my communications however, I have to say that I was sadly disappointed in the meal service during a recent visit to a nursing facility. Was it because it was a Saturday evening meal and they had less staff? Is that an excuse for serving soggy, ground up pizza and overcooked mushy green beans to a person who is unable to articulately communicate her dislike of the food? Certainly not.

Are your customers satisfied with their dining experience? National surveys in nursing facilities have indicated that almost a third of residents are unhappy with the food, and almost a quarter are unhappy with the dining experience. Food/meal satisfaction is considered a quality of life marker, so attention to satisfaction is critical. After all, food is a major part of daily life. It’s much more than nutrition and hydration; it’s an important part of psychological, social, cultural, religious, and family traditions. Aromas, flavors, and textures of food can brighten someone’s day by eliciting happy memories, and providing a feeling of comfort.

Every individual has the right to choose:

what to eat,

who to eat with,

when to eat, and

where to eat.

Residents also have the right to refuse therapeutic or mechanically altered diets, ask for a meal replacement if they dislike the food, and most importantly, they have the right to be treated with dignity and respect at meal time.

Making Meal Time Special

Meals are an important part of the culture of any health care facility and are usually highly anticipated by residents. By one estimate, roughly 60% of the average resident’s day revolves around preparing for, attending, and returning from meals. Dining should focus on individual choice and provide person-directed care.

Today’s health care consumers are accustomed to choice, and they often have very specific food preferences and dietary habits. Meeting individual needs can be a challenge, but it is essential to maintain health and well-being.

Increasing Choices Available at Meals

The way you deliver food can help promote more food choices for your residents. Creative dining programs have been shown to demonstrate improvements in food intake and/or quality of life. There are many ways to offer food choices:

Access to foods and beverages throughout the day and night from kitchenettes or pantries

Customer Service

Providing excellent customer service involves knowing who your customers are and what they want. As the baby boomer population ages, residents entering skilled nursing facilities for rehabilitation and short term stays will most likely have sophisticated palates and be accustomed to excellent customer service. They won’t hesitate to complain about poor quality meals. So why not invite comments and seek input for your menus and meal service?

Customer service and hospitality training can help improve customer service. Concerns or complaints should be taken seriously and addressed in a timely manner. Staff assigned to the dining room should: be trained to find the best solution for each individual complaint, encourage residents to eat and cue or assist residents with dining as needed, and retrieve items that are requested. If table service is provided, they should be trained on proper procedures for waiting on residents.

Short staffed? Consider cross-training staff from other departments to assist with meal service: serving food, opening containers, cutting food, for residents who eat independently. This allows trained nursing assistants more time to help those who need more assistance to eat the meal.

Providing Quality Food

High quality food temperature is essential to keeping customers happy. Assure that meals taste good, are served at the right temperature, have a pleasant aroma, are nourishing, and satisfy special dietary needs, cultural and/or religious preferences, and food preferences.

There are many aspects involved in preparing and serving quality food. A dining services manager who is passionate about food and service is also enthusiastic about leading staff to make quality improvements: encouraging cooks and food service workers to keep their skills up to date, providing regular education on food preparation and presentation, and encouraging staff to create new ideas for foods and recipes that residents will love. If possible, consider bringing a chef in to your facility to train staff, or even hiring a chef to enhance the quality of the food.

Dining services managers can help assure high quality food by:

Following well planned menus and recipes, using the freshest ingredients. (Always share your menu with residents in advance.)

Cooking and seasoning food properly so it isn’t overcooked or undercooked. (Always taste and approve foods prior to service).

Assuring food is plated attractively, using garnishes to enhance the appearance of the food as appropriate.

Use liberalized diets where appropriate to help make food more flavorful and appealing. Individualize diets to meet residents’ personal needs and desires. If therapeutic or mechanically altered diets are needed, foods served should be just as flavorful and attractive as the food served for the regular diet.

01/19/2016

One of my RDNs posed this question recently related to BMI levels for older adults:

I've been seeing transfer notes from the hospital and other nursing homes with diet/nutrition histories where RDNs are charting that BMIs of less than 23 is underweight. For example, one note documented that a BMI of 21.3 was underweight "for age" for a man who was 92. State surveyors are also asking for a list of residents with BMI under 21 and wanting to see interventions on them. The MDS does not trigger for a low BMI until under 19. Do we need to adapt our practices?

The National Institute of Health classification of overweight and obesity by body mass index (BMI) is as follows:

Classification

Obesity Class

BMI (kg/m2)

Normal

18.5-24.9

Overweight

25.0-29.9

Obesity

I

30.0-34.9

Obesity

II

35.0-39.9

Extreme Obesity

III

> 40

BMI is interpreted based on age, health history, usual body weight, and weight history.

Adults should be assessed for indicators of nutritional status and decline using body mass index (BMI) as one of many factors. Data suggests that a higher BMI range may be protective in older adults and that the standards for ideal weight (BMI of 18.5 to 25) may be too restrictive in the elderly. A lower BMI may be considered detrimental to older adults due to association with declining nutrition status, potential pressure ulcers, infection and other complications. A BMI of 19 or less may indicate nutritional depletion, while a BMI of 30 or above indicates obesity.

In the literature, there is a lot of conversation about a BMI of 21-23 (rather than 18/19) as considered on the low side for older adults. At the same time, there is a lot of conversation about the “obesity paradox” saying a higher BMI might be protective against some diseases and death. There is still a lot of controversy regarding the efficacy of BMI for older adults, regardless of what is considered “too low” or “too high”.

To our knowledge, there are no firm recommendations from any source on BMI cutoffs for older adults. The MDS triggers a CAA if BMI is < 18.5, although as stated above a higher BMI can probably be considered too low for older adults.

In clinical practice, the BMI number is not as important as how it compares to an individual’s history. Monitoring changes over time is what is important.

If state surveyors question whether everyone with a low BMI needs an intervention, consider explaining that if a low BMI was normal for this person’s life history, then we would not attempt to correct it - although interventions might be put in place for other reasons (poor intake, weight loss, wounds, etc.). And for an older person with a high BMI of 35 who had been overweight their whole life, it is highly likely that lifestyle and habits are set and weight loss would probably not be necessary or successful in older age.

The new Academy/ASPEN criteria for diagnosing malnutrition does not use BMI – it uses unintended weight loss, body fat, muscle mass loss (as determined by nutrition focused physical assessment and/or handgrip strength in the case of severe malnutrition) and other factors. The National Quality Forum Measure #128 (NWF 0421) Preventive Care and Screening uses >23 and <30 for those over the age of 65.

There are several reference articles on BMI in the elderly which all suggest higher BMIs for those over 65:

01/07/2016

Most of us can say that our lives have been touched by Alzheimer’s Disease or dementia in some way, and with the aging of America, the number of people affected by this condition continues to increase. The term dementia describes a variety of diseases and conditions that develop when neurons in the brain no longer function normally, causing changes in memory, behavior, and ability to think clearly. There are many types of dementia, but Alzheimer’s disease (AD) is the most common form, accounting for 60-80% of dementia cases. About 1 in 9 people aged 65 and older, and 1 in 3 of those age 85 and older have AD.

Alzheimer’s disease is irreversible and is progressive over time, advancing from mild to moderate to severe. Treatment can slow the progression and sometimes help manage symptoms, but there is no cure. The time from diagnosis to death varies from as little to 3 or 4 years in older persons to as long as 10 years in those who are younger when diagnosed. The cost of AD to the U.S. health care system is significant. Average per-person Medicare costs for those with AD and other forms of dementia are three times higher than for those without these conditions.

Risk Factors for Alzheimer’s Disease

Some risk factors for Alzheimer's disease, such as age and genetic profile, can’t be controlled. However, certain lifestyle factors, such as a nutritious diet, exercise, social engagement, and mentally stimulating pursuits, might help to reduce the risk of cognitive decline and AD. Scientists are looking for associations between cognitive decline and heart disease, high blood pressure, diabetes, and obesity. Understanding these relationships will help us understand whether reducing risk factors for these diseases may also help with Alzheimer's.

A growing body of evidence suggests that certain dietary components (such as antioxidant nutrients, fish, unsaturated fats, B-vitamins, and omega-3 fatty acids) may help protect against age-related cognitive decline and AD. As research unfolds, health care professionals may be able to recommend specific diet and/or lifestyle changes to help prevent AD.

Medical Nutrition Therapy for Alzheimer’s Disease

A comprehensive nutrition assessment should be a routine part of the care of individuals with AD. A number of issues can affect the nutritional status of a person with AD, but each individual will have a different nutrition diagnosis and nutrition prescription.

Medications or poorly-fitting dentures can affect food intake. As cognitive status declines, changes in neurologic function can result in problems with eating such as impaired attention span, reasoning, and the ability to recognize feelings of hunger, thirst, and satiety. As AD progresses, the individual may forget how to use eating utensils, forget to chew without verbal cues, and forget how to swallow. Motor skills may decline, resulting in a need for feeding assistance. Excessive wandering and the inability to consume adequate nutrients may contribute to unintended weight loss, which is often unavoidable in those with advanced dementia. Researchers theorize that this is because of the disease process, although the exact reasons are not clear.

There is no one diet recommended for treatment of AD. Each individual will require a unique set of nutritional interventions depending on their condition, symptoms, and stage of the disease. Potential interventions include:

Changing the dining environment: Provide a quiet environment, without distractions. Limit choices by providing one dish of food at a time. Use colorful dishes to differentiate food from the plate.

Consistency-modified diets for those with chewing or swallowing difficulty.

Therapeutic diets that restrict sodium, concentrated sweets, or other components of the diet are generally not recommended in people with end-stage AD because the primary goal of care is to prevent unintended weight loss and provide the highest quality of life possible.

End of Life Nutrition Issues

As meal intake declines in the individual with advanced AD, families and/or responsible parties may want to consider placement of a PEG tube for artificial nutrition and hydration. However, feeding tubes are rarely effective in improving nutrition, maintaining skin integrity through increased protein intake, preventing aspiration pneumonia, minimizing suffering, improving functional status, or extending life in dementia patients. Based on the evidence available, most experts agree that hand feeding of food and fluids rather than tube feeding should be recommended for the best quality of life during end-of-life care. Despite the evidence, some families will request of tube feeding. The registered dietitian nutritionist can provide information and guidance to help families make the decisions regarding initiating tube feeding and managing complications.

When a person with end-stage dementia is hand fed, food and fluids may need to be altered in consistency for easier consumption or to manage swallowing problems. The individual should be encouraged to consume foods that bring them comfort or are associated with pleasure or good memories. Unlike tube feeding, hand feeding may not meet 100% of a person’s nutrition and fluid needs. It can, however, satisfy other important basic needs like enjoying the process of eating, appreciating flavors and textures of food, human touch and interaction, and the routine of sharing a meal with others.

Becky Dorner, RDN, LD, FAND is widely-known as one of the nation's leading experts on nutrition and long-term health care. Her company, Becky Dorner & Associates, Inc. (BDA) is a trusted source of valuable resources dedicated to improving quality of life for older adults. For valuable resources for healthcare professionals, visit www.beckydorner.com and sign up for our free membership.

01/13/2015

Keeping clinical skills consistent with current standards of practice in dietetics is essential. All nutrition professionals have a duty to demonstrate a level of clinical expertise that is consistent with current standards of practice in dietetics. If time is an issue, set a goal to sharpen your clinical detection skills over the next 6-12 months. There are numerous books, webinars and CE courses on NFPA available at www.beckyDorner.com to help you learn this vital component of nutrition assessment.

Myth #2: I don’t use Nutrition Care Process (NCP) so NFPA will not fit into my current assessment and documentation practices.

NCP has been the standard of practice in dietetics for over 10 years. If you have not started using it, now is a great time to update your assessment and documentation methodology to be consistent with standards of practice. NFPA is one of the five components of nutrition assessment in the nutrition care process. It is based on a focused hands-on assessment evaluating body systems for evidence of nutrient deficiencies or toxicities. For example signs of muscle and subcutaneous fat wasting, poor oral health, impaired ability to suck, swallow or breathe, changes in appetite and abnormal affect. Findings are usually consistent with anthropometric measurements, biochemical data and dietary intake, but not always. The goal of NFPA is to determine if there are physical changes that have resulted from suboptimal food and/or water intake. It is a tool to help the medical team “connect the dots” that lead to an accurate medical diagnosis and as a measuring stick to evaluate the effectiveness of MNT.

Myth #3: I’ve never seen a patient with malnutrition or vitamin mineral deficiencies so I don’t need to use NFPA.

One reason clinicians don’t see malnutrition or vitamin mineral deficiencies is because they aren’t looking for them. The Academy of Nutrition & Dietetics and American Society for Enteral and Parenteral Nutrition have published Consensus Guidelines on Characteristics of Malnutrition for adults and children. There is more evidence in the scientific literature of patients with vitamin and mineral deficiencies related to food insecurity, chronic diseases, medications, and malabsorptive surgeries. When you start using NFPA, you will find individuals who manifest signs and symptoms of malnutrition and vitamin-mineral deficiencies. NFPA is a tool to improve health outcomes and reduce healthcare costs.

Myth # 4: I’m sure my department manager would not allow RDNs the time to do NFPA.

Now is the time to speak with your manager about the doing NFPA as part of the NCP. If you are not doing NFPA, then you are excluding a component of NCP in your nutrition assessments. Individuals working in supervisory roles expect professional staff to be “on the cutting edge” and to continually learn how to improve clinical skills. Healthcare reform is changing the landscape of medical care and professionals are taking on new roles and responsibilities. Use the climate of healthcare reform to add NFPA to your practice.

Myth # 5: I don’t feel comfortable touching patients.

NFPA does require you to touch the patient and it important to feel comfortable in this role. Practicing NFPA skills on friends and family will help you overcome these fears. It is vital to use universal precautions and standards set by your healthcare organization for infection control. If you are unfamiliar with these precautions, your manager can help you identify educational resources specific to your healthcare organization.

Myth # 6: I’m afraid the nurses and doctors will feel threatened if I do hands on assessment.

If RDNs in your facility are not currently doing NFPAs, it is important to notify the medical team ahead of time that RDNs will be doing hands on assessments. This is an opportunity to work collaboratively with the medical team. Map out a strategy with your supervisor to initiate this change in practice. Ask other members of the medical team to allow RDNs to shadow them and work collaboratively on hands-on assessments. Explain that this will help you to be a more integral part of the team. You can also ask experienced colleagues for opportunities to shadow them at work.

Myth # 7: I’ve been a clinician for 25 years. It’s really tough for me to learn anything new.

None of us like to work out of our comfort zone. However, as a credentialed professional you have the responsibility to stay current with standards of practice. NFPA is part of NCP. NCP is the standard of practice for nutrition professionals. Once you step out of your comfort zone, you will likely find NFPA to be an invaluable addition for your professional toolkit. Take steps to learn more about NFPA and soon you will find that this is an essential component of clinical nutrition practice.

Start learning now with our webinar on this timely topic. Additional continuing education resources on NFPA, are available as well. Best wishes in your quest to expand your skill set and make yourself more valuable!